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“With Women” Midwives for Afghanistan Reproductive Health Workforce Development in Afghanistan 2002 - 2009 Jeffrey Smith, MD, MPH Asia Regional Technical.

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Presentation on theme: "“With Women” Midwives for Afghanistan Reproductive Health Workforce Development in Afghanistan 2002 - 2009 Jeffrey Smith, MD, MPH Asia Regional Technical."— Presentation transcript:

1 “With Women” Midwives for Afghanistan Reproductive Health Workforce Development in Afghanistan 2002 - 2009 Jeffrey Smith, MD, MPH Asia Regional Technical Director Jhpiego

2 2 Presentation Outline  Review the reproductive health situation in Afghanistan  Discuss the human resource constraints  Describe some key considerations in workforce development/task shifting in reproductive health  Present the results of interventions in Afghanistan

3 3 RH Situation 2002  High maternal and newborn mortality (MMR 1600 / 100 000 LB)  Few RH providers  40% facilities with female staff  467 midwives in country  Non-uniformity of qualification  Out of date skills  No functional schools for training midwives – schools closed by Taliban  RH de-emphasized in medical curriculum  Disarray of system for supporting human resources for health  STRATEGY: support the education and deployment of large numbers of midwives rather than doctors

4 Task Shifting Putting clinical capability in hands of appropriate peripheral workers so that key components of health care can be diffused to greatest number of people. Should not be a temporary fix! But a professional focus! 4

5 5 What works, who works, and where?  Health Center Intrapartum Care Strategy  Training of Midwives  Staffing of Health Centers  Health system linkages  Capability in Basic EmOC  Clarity about “skilled attendant”  Policy support for clinical authority  Educational system to achieve competency and capability Lancet 2006 Maternal Survival Series

6 6 Workforce Assessment & Planning Array of semi trained, partially skilled workers NEEDHAVE Core group of leaders and academics Group of managers and teachers Bulk of personnel should be service providers Cries of crisis: “Something is better than nothing”

7 7 Normatizing the Health Workforce  Re-establish health system accountability  Census of health workers  Including where they work  Testing: knowledge + skills  Phased (re)deployment  Registration and licensure  Upgrade programs  Education programs  Set selected practical policies  Immediate need and long term view  Emergency  Development Staff functioning as midwives Qualified License and Deploy Almost qualified Upgrade Standardize and Retain Unqualified Retrain to qualification, Redeploy

8 8 Importance of Standardization  Single, standard approach to upgrading RH workforce may be more efficient, especially in post-conflict settings  Fragile health systems don’t have resources to compare and contrast different, non- uniform approaches at macro level  Uniformity of professional and community expectation, supervision, supply, etc.

9 9 Policy and Structure  Basic Package of Health Services  Maternal Health / RH Service delivery guidelines  Guide for re-establishing services and in-service training/pre- service education  National MW education policy  Midwifery job description  Single, unified national midwifery curriculum  Assessment materials and criteria  of students  graduation and licensure  of clinical facilities  quality of care and clinical certification  of schools  school accreditation

10 10 Standardization in Action  Standard curriculum and detailed teaching resources  National accreditation system  Based on “recipe” for establishing and running a midwifery school  Structured technical assistance framework  Increased local capacity and improved ability to support training programs and schools in remote or insecure areas

11 11 Keep it clinical  Ensure that the focus remains on clinical skill development  MW program in Afghanistan was SHORTENED from 3 years to 2 and unnecessary topics were removed  Semester 1: Normal Pregnancy  Semester 2: Complications  Semester 3: Family Planning, RH and Child Care

12 12 Keep it local  Retention, deployment, selection and education all related:  local control increases local commitment  Train midwives where they are needed  Focus on local, “micro- deployment”  Caveat: ensure adequate educational and clinical capacity

13 13

14 14 Results 2002 – 2009  5 midwifery schools re- opened and 26 new midwifery schools established  Midwifery deployment  1961 new midwives  85% deployed  86% working as midwives  Health centers with 1+ female health worker: 25%  83%  Health centers staffed with 1+ midwife: <10%  61%  Standardized system to improve quality in midwifery services and education

15 15 Working as Midwives, 2009 ProgramCurrently studyingEnrolledGraduatedDrop-outs% GraduatedDeployed/Employed% Deployed/Employment ofgraduatedCurrently working(as of May, 2009)% currentlyworking ofgraduatedCurrently workingof deployed/employed IHS1671232110312990%89081%75468%85% CME5098868582897%78591%69481%88% Total6762118196115793%167585%144874%86% Local CME schools have greater success than regional IHS programs.

16 16

17 17 Deliveries by Skilled Attendants Selected Provinces/Districts Tarkhar: from 12% to 21% Herat: from 13% to 27% Examples of increase in skilled birth attendant coverage at birth:

18 18 Professionalization of Midwifery Afghan Midwives Association  Founded in 2005  Provincial branch in most provinces  Roles:  Advocacy  Professional development  Networking and support  Has raised personal and professional stature of midwifery “This is the first time I have ever belonged to anything other than my own family. I feel proud to be a midwife.”

19 19 Reflection on “Gender” Task shifting should not become Clinical Shortcutting Shortcuts in medical education vs. Shortcuts in midwifery education

20 20 Conclusions  Vibrant maternal health / reproductive health workforce must be composed substantially of midwives  Midwives must be empowered professionally and deployed rationally  Consistency in the service delivery and educational system is essential for midwives to have skills and retain skills

21 21 Acknowledgements  Ministry of Public Health, Afghanistan  Donors – USAID, World Bank and European Commission  Non Governmental Organization partners, WHO, UNICEF, and many other supporters of midwifery  Staff and students of all midwifery schools

22 22 Thank you  Questions?  Comments?  Observations?

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